Part 1 — Basic Info and Pain Evaluation

This section is to help gather basic information, which can help you to keep track and
measure changes and improvements from your work with The Body Code. Do your best to
answer the following questions as accurately as possible. Fill out the form entirely for each
session if desired.

Name:

Basics Date: Age: Gender: F M

Please fill out the fields below, choosing the most

problematic issues and rating them from 1 to 10, based
on your average daily, weekly or monthly experience. A
Issues, Goals one is most minor, a ten is most severe. Using this pain
scale can help us to identify the severity of the issue(s).
and Pain You’ll gather these same pieces of information again
later on after doing some Body Code work, to measure
Evaluation any changes and/or improvement.

Issue:

How painful, problematic or difficult is this issue (1-10)? Pre Session Post Session

How long has it been going on?

Issue:

How painful, problematic or difficult is this issue (1-10)? Pre Session Post Session

How long has it been going on?

Issue:

How painful, problematic or difficult is this issue (1-10)? Pre Session Post Session

How long has it been going on?

Issue:

How painful, problematic or difficult is this issue (1-10)? Pre Session Post Session

How long has it been going on?

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Part 2 — History Evaluation
This section is designed to gather information about experiences with these issues in the
past, which can bring to light important issues to focus on for an ultimate healing process.

Please describe your family situation while growing up as it relates to these issues:

What (if anything) triggered the onset of this problem?

Are there any traumas you feel may be related to any of these issues, even indirectly?

Please list any family members or partners who have or have had similar issues:

Please describe anything else that may be pertinent or useful to know:

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Part 3 — Goals and Visualization
This section is to help you create the vibration of the reality you want, which enables your
subconscious computer to look for conflicts. This makes doing work with The Body Code
easier and more targeted, which can help you to achieve your goals faster!

If you suddenly felt the perfect amount of energy and had no pain of any kind, what would

you be able to do with it?

If you felt really good all the time, how would you help the world?

What would an average day look like if you never had to worry about these issues again?

If these issues went away tomorrow, how would you feel? (focus on each issue at a time if

you think it may be helpful).

Load up on these positive feelings and get excited about the future! What do you feel now?

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Part 4 — The Work
This section is to walk you through identifying the right issue to work on, and then
identifying and releasing any underlying causes (which may themselves have underlying
causes too!). This will help make sure you never miss a step.

Section 1. (How to Find Imbalance 1 and Any of its Underlying Causes)

Which issue is the priority now?

Ask: “What is causing this issue?” Locate Imbalance 1 on The Body Code chart and write it
down in the box below, including any necessary information as the chart directs.
1.

Ask, “Can we release/correct this now?”

If Yes:
Follow directions on chart to release/correct. Then move to Section 2.
If No:
Ask: “Do we need to know more about it?” If yes, follow directions on chart to find the
necessary information, then ask again: “Can we release / correct this now?”
If No:
Ask: “Is there an underlying imbalance causing Imbalance Number 1?”
If yes, fill out the box(es) below (Section 1a), writing down and clearing the underlying
imbalance. Then repeat the question, clearing any more imbalances that you find, one by
one, and staying in Section 1a until your answer is “no”. Then ask again, “Can we release/
correct this now?” and your answer should be yes. Then move on to Section 2.

Section 1a

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Section 2.
Identify what issue needs to be worked on. Start by asking, “Is there another imbalance
causing this same issue as in Section 1?”

If No, ask, “Can we work on another issue at this time?” If yes, ask, “What is the next issue that

needs to be worked on?” and fill in the issue below. If it is the same issue as in Section 1, note

it here also:

(If you cannot work on another issue, then you are likely unable to do more work at this time).

Ask: “What is causing this issue?” Locate Imbalance 2 on The Body Code chart and enter here

2.

Ask, “Can we release/correct this now?”

If Yes:
Follow directions on chart to release/correct. Then move to Section 3.
If No:
Ask: “Do we need to know more about it?” If yes, follow directions on chart to find the
necessary information, then ask again: “Can we release / correct this now?”
If No:
Ask: “Is there an underlying imbalance causing Imbalance Number 2?”
If yes, fill out the box(es) below (Section 2a), writing down and clearing the underlying
imbalance. Then repeat the question, clearing any more imbalances that you find, one by
one, and staying in Section 2a until your answer is “no”. Then ask again, “Can we release/
correct this now?” and your answer should be yes. Then move on to Section 3.

Section 2a

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Section 3.
Identify what issue needs to be worked on. Start by asking, “Is there another imbalance
causing this same issue as in Section 1 or 2?”

If No, ask, “Can we work on another issue at this time?” If yes, ask, “What is the next issue that

needs to be worked on?” and fill in the issue below. If it is the same issue as in Section 1 or 2,

note it here also:

(If you cannot work on another issue, then you are likely unable to do more work at this time).

Ask: “What is causing this issue?” Locate Imbalance 3 on The Body Code chart and enter here

3.

Ask, “Can we release/correct this now?”

If Yes:
Follow directions on chart to release/correct. Then move to Section 4.
If No:
Ask: “Do we need to know more about it?” If yes, follow directions on chart to find the
necessary information, then ask again: “Can we release / correct this now?”
If No:
Ask: “Is there an underlying imbalance causing Imbalance Number 3?”
If yes, fill out the box(es) below (Section 3a), writing down and clearing the underlying
imbalance. Then repeat the question, clearing any more imbalances that you find, one by
one, and staying in Section 3a until your answer is “no”. Then ask again, “Can we release/
correct this now?” and your answer should be yes. Then move on to Section 4.

Section 3a

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Section 4.
Identify what issue needs to be worked on. Start by asking, “Is there another imbalance
causing this same issue as in Section 1, 2 or 3?”

If No, ask, “Can we work on another issue at this time?” If yes, ask, “What is the next issue that

needs to be worked on?” and fill in the issue below. If it is the same issue as in Section 1-3,

note it here also:

(If you cannot work on another issue, then you are likely unable to do more work at this time).

Ask: “What is causing this issue?” Locate Imbalance 4 on The Body Code chart and enter here

4.

Ask, “Can we release/correct this now?”

If Yes:
Follow directions on chart to release/correct. Then move to Section 5.
If No:
Ask: “Do we need to know more about it?” If yes, follow directions on chart to find the
necessary information, then ask again: “Can we release / correct this now?”
If No:
Ask: “Is there an underlying imbalance causing Imbalance Number 4?”
If yes, fill out the box(es) below (Section 4a), writing down and clearing the underlying
imbalance. Then repeat the question, clearing any more imbalances that you find, one by
one, and staying in Section 4a until your answer is “no”. Then ask again, “Can we release/
correct this now?” and your answer should be yes. Then move on to Section 5.

Section 4a

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Section 5.
Identify what issue needs to be worked on. Start by asking, “Is there another imbalance
causing this same issue as in Section 1, 2, 3 or 4?”

If No, ask, “Can we work on another issue at this time?” If yes, ask, “What is the next issue that

needs to be worked on?” and fill in the issue below. If it is the same issue as in Section 1-4,

note it here also:

(If you cannot work on another issue, then you are likely unable to do more work at this time).

Ask: “What is causing this issue?” Locate Imbalance 5 on The Body Code chart and enter here

5.

Ask, “Can we release/correct this now?”

If Yes:
Follow directions on chart to release/correct. Then move to Section 6.
If No:
Ask: “Do we need to know more about it?” If yes, follow directions on chart to find the
necessary information, then ask again: “Can we release / correct this now?”
If No:
Ask: “Is there an underlying imbalance causing Imbalance Number 5?”
If yes, fill out the box(es) below (Section 5a), writing down and clearing the underlying
imbalance. Then repeat the question, clearing any more imbalances that you find, one by
one, and staying in Section 5a until your answer is “no”. Then ask again, “Can we release/
correct this now?” and your answer should be yes. Then move on to Section 6.

Section 5a

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Section 6.
Identify what issue needs to be worked on. Start by asking, “Is there another imbalance
causing this same issue as in Section 1, 2, 3, 4 or 5?”

If No, ask, “Can we work on another issue at this time?” If yes, ask, “What is the next issue that

needs to be worked on?” and fill in the issue below. If it is the same issue as in Section 1-5,

note it here also:

(If you cannot work on another issue, then you are likely unable to do more work at this time).

Ask: “What is causing this issue?” Locate Imbalance 6 on The Body Code chart and enter here

6.

Ask, “Can we release/correct this now?”

If Yes:
Follow directions on chart to release/correct. Then move to Section 7.
If No:
Ask: “Do we need to know more about it?” If yes, follow directions on chart to find the
necessary information, then ask again: “Can we release / correct this now?”
If No:
Ask: “Is there an underlying imbalance causing Imbalance Number 6?”
If yes, fill out the box(es) below (Section 6a), writing down and clearing the underlying
imbalance. Then repeat the question, clearing any more imbalances that you find, one by
one, and staying in Section 6a until your answer is “no”. Then ask again, “Can we release/
correct this now?” and your answer should be yes. Then move on to Section 7.

Section 6a

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Section 7.
Identify what issue needs to be worked on. Start by asking, “Is there another imbalance
causing this same issue as in Section 1 through 6?”

If No, ask, “Can we work on another issue at this time?” If yes, ask, “What is the next issue that

needs to be worked on?” and fill in the issue below. If it is the same issue as in Section 1-6,

note it here also:

(If you cannot work on another issue, then you are likely unable to do more work at this time).

Ask: “What is causing this issue?” Locate Imbalance 7 on The Body Code chart and enter here

7.

Ask, “Can we release/correct this now?”

If Yes:
Follow directions on chart to release/correct. Then move to Section 8.
If No:
Ask: “Do we need to know more about it?” If yes, follow directions on chart to find the
necessary information, then ask again: “Can we release / correct this now?”
If No:
Ask: “Is there an underlying imbalance causing Imbalance Number 7?”
If yes, fill out the box(es) below (Section 7a), writing down and clearing the underlying
imbalance. Then repeat the question, clearing any more imbalances that you find, one by
one, and staying in Section 7a until your answer is “no”. Then ask again, “Can we release/
correct this now?” and your answer should be yes. Then move on to Section 8.

Section 7a

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Section 8.
Identify what issue needs to be worked on. Start by asking, “Is there another imbalance
causing this same issue as in Section 1 through 7?”

If No, ask, “Can we work on another issue at this time?” If yes, ask, “What is the next issue that

needs to be worked on?” and fill in the issue below. If it is the same issue as in Section 1-7,

note it here also:

(If you cannot work on another issue, then you are likely unable to do more work at this time).

Ask: “What is causing this issue?” Locate Imbalance 8 on The Body Code chart and enter here

8.

Ask, “Can we release/correct this now?”

If Yes:
Follow directions on chart to release/correct. Then move to Section 9.
If No:
Ask: “Do we need to know more about it?” If yes, follow directions on chart to find the
necessary information, then ask again: “Can we release / correct this now?”
If No:
Ask: “Is there an underlying imbalance causing Imbalance Number 8?”
If yes, fill out the box(es) below (Section 8a), writing down and clearing the underlying
imbalance. Then repeat the question, clearing any more imbalances that you find, one by
one, and staying in Section 8a until your answer is “no”. Then ask again, “Can we release/
correct this now?” and your answer should be yes. Then move on to Section 9.

Section 8a

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Section 9.
Identify what issue needs to be worked on. Start by asking, “Is there another imbalance
causing this same issue as in Section 1 through 8?”

If No, ask, “Can we work on another issue at this time?” If yes, ask, “What is the next issue that

needs to be worked on?” and fill in the issue below. If it is the same issue as in Section 1-8,

note it here also:

(If you cannot work on another issue, then you are likely unable to do more work at this time).

Ask: “What is causing this issue?” Locate Imbalance 9 on The Body Code chart and enter here

9.

Ask, “Can we release/correct this now?”

If Yes:
Follow directions on chart to release/correct. Then move to Section 10.
If No:
Ask: “Do we need to know more about it?” If yes, follow directions on chart to find the
necessary information, then ask again: “Can we release / correct this now?”
If No:
Ask: “Is there an underlying imbalance causing Imbalance Number 9?”
If yes, fill out the box(es) below (Section 9a), writing down and clearing the underlying
imbalance. Then repeat the question, clearing any more imbalances that you find, one by
one, and staying in Section 9a until your answer is “no”. Then ask again, “Can we release/
correct this now?” and your answer should be yes. Then move on to Section 10.

Section 9a

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Section 10.
Identify what issue needs to be worked on. Start by asking, “Is there another imbalance
causing this same issue as in Section 1 through 9?”

If No, ask, “Can we work on another issue at this time?” If yes, ask, “What is the next issue that

needs to be worked on?” and fill in the issue below. If it is the same issue as in Section 1-9,

note it here also:

(If you cannot work on another issue, then you are likely unable to do more work at this time).

Ask: “What is causing this issue?” Locate Imbalance 10 on The Body Code chart and enter here

10.

Ask, “Can we release/correct this now?”

If Yes:
Follow directions on chart to release/correct. Then move to Section 11.
If No:
Ask: “Do we need to know more about it?” If yes, follow directions on chart to find the
necessary information, then ask again: “Can we release / correct this now?”
If No:
Ask: “Is there an underlying imbalance causing Imbalance Number 10?”
If yes, fill out the box(es) below (Section 10a), writing down and clearing the underlying
imbalance. Then repeat the question, clearing any more imbalances that you find, one by
one, and staying in Section 10a until your answer is “no”. Then ask again, “Can we release/
correct this now?” and your answer should be yes. Then move on to Section 11.

Section 10a

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Section 11.
Identify what issue needs to be worked on. Start by asking, “Is there another imbalance
causing this same issue as in Section 1 through 10?”

If No, ask, “Can we work on another issue at this time?” If yes, ask, “What is the next issue that

needs to be worked on?” and fill in the issue below. If it is the same issue as in Section 1-10,

note it here also:

(If you cannot work on another issue, then you are likely unable to do more work at this time).

Ask: “What is causing this issue?” Locate Imbalance 11 on The Body Code chart and enter here

11.

Ask, “Can we release/correct this now?”

If Yes:
Follow directions on chart to release/correct. Then move to Section 12.
If No:
Ask: “Do we need to know more about it?” If yes, follow directions on chart to find the
necessary information, then ask again: “Can we release / correct this now?”
If No:
Ask: “Is there an underlying imbalance causing Imbalance Number 11?”
If yes, fill out the box(es) below (Section 11a), writing down and clearing the underlying
imbalance. Then repeat the question, clearing any more imbalances that you find, one by
one, and staying in Section 11a until your answer is “no”. Then ask again, “Can we release/
correct this now?” and your answer should be yes. Then move on to Section 12.

Section 11a

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Section 12.
Identify what issue needs to be worked on. Start by asking, “Is there another imbalance
causing this same issue as in Section 1 through 11?”

If No, ask, “Can we work on another issue at this time?” If yes, ask, “What is the next issue that

needs to be worked on?” and fill in the issue below. If it is the same issue as in Section 1-11,

note it here also:

(If you cannot work on another issue, then you are likely unable to do more work at this time).

Ask: “What is causing this issue?” Locate Imbalance 12 on The Body Code chart and enter here

12.

Ask, “Can we release/correct this now?”

If Yes:
Follow directions on chart to release/correct. Then move to Section 13.
If No:
Ask: “Do we need to know more about it?” If yes, follow directions on chart to find the
necessary information, then ask again: “Can we release / correct this now?”
If No:
Ask: “Is there an underlying imbalance causing Imbalance Number 12?”
If yes, fill out the box(es) below (Section 12a), writing down and clearing the underlying
imbalance. Then repeat the question, clearing any more imbalances that you find, one by
one, and staying in Section 12a until your answer is “no”. Then ask again, “Can we release/
correct this now?” and your answer should be yes. Then move on to Section 13.

Section 12a

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